|
NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]
|
Facility
|
OP
|
$0.23
|
|
|
Service Code
|
NDC 0121104516
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.20
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Senior |
$0.14
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.11
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.09
|
| Rate for Payer: TriValley Medical Group Senior |
$0.09
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: Vantage Medical Group Senior |
$0.20
|
|
|
NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM [5754]
|
Facility
|
IP
|
$1.68
|
|
|
Service Code
|
NDC 5167212631
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.26 |
| Rate for Payer: Adventist Health Commercial |
$0.34
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.08
|
| Rate for Payer: Cash Price |
$0.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.91
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.14
|
| Rate for Payer: Heritage Provider Network Senior |
$1.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.42
|
| Rate for Payer: Multiplan Commercial |
$1.26
|
|
|
NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM [5754]
|
Facility
|
OP
|
$1.68
|
|
|
Service Code
|
NDC 5167212631
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.43 |
| Rate for Payer: Adventist Health Commercial |
$0.34
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.43
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.92
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.84
|
| Rate for Payer: Blue Shield of California Commercial |
$1.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.82
|
| Rate for Payer: Cash Price |
$0.76
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.43
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.04
|
| Rate for Payer: Heritage Provider Network Senior |
$1.04
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.80
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.42
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.18
|
| Rate for Payer: Multiplan Commercial |
$1.26
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.67
|
| Rate for Payer: TriValley Medical Group Senior |
$0.67
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.84
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.84
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.43
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.43
|
| Rate for Payer: Vantage Medical Group Senior |
$1.43
|
|
|
OBINUTUZUMAB 1,000 MG/40 ML INTRAVENOUS SOLUTION [204196]
|
Facility
|
IP
|
$283.51
|
|
|
Service Code
|
HCPCS J9301
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$51.32 |
| Max. Negotiated Rate |
$212.63 |
| Rate for Payer: Adventist Health Commercial |
$56.70
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$182.58
|
| Rate for Payer: Cash Price |
$127.58
|
| Rate for Payer: Cigna of CA HMO/PPO |
$130.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$153.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$131.27
|
| Rate for Payer: Heritage Provider Network Senior |
$131.27
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$51.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$70.88
|
| Rate for Payer: Multiplan Commercial |
$212.63
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$102.43
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$93.87
|
|
|
OBINUTUZUMAB 1,000 MG/40 ML INTRAVENOUS SOLUTION [204196]
|
Facility
|
OP
|
$283.51
|
|
|
Service Code
|
HCPCS J9301
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$51.32 |
| Max. Negotiated Rate |
$212.63 |
| Rate for Payer: Adventist Health Commercial |
$56.70
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$175.21
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$126.69
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$92.91
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$84.46
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$125.07
|
| Rate for Payer: Blue Shield of California Commercial |
$84.06
|
| Rate for Payer: Blue Shield of California EPN |
$84.06
|
| Rate for Payer: Cash Price |
$127.58
|
| Rate for Payer: Cash Price |
$127.58
|
| Rate for Payer: Cigna of CA HMO/PPO |
$130.41
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$105.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$92.91
|
| Rate for Payer: Dignity Health Medicare Advantage |
$92.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$181.45
|
| Rate for Payer: EPIC Health Plan Medicare |
$84.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$131.27
|
| Rate for Payer: Heritage Provider Network Senior |
$131.27
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$84.46
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$135.23
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$51.32
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$97.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$70.88
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$113.18
|
| Rate for Payer: Multiplan Commercial |
$212.63
|
| Rate for Payer: TriValley Medical Group Commercial |
$113.40
|
| Rate for Payer: TriValley Medical Group Senior |
$113.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$102.43
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$93.87
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$105.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$92.91
|
| Rate for Payer: Vantage Medical Group Senior |
$92.91
|
|
|
OCTREOTIDE ACETATE 1,000 MCG/ML INJECTION SOLUTION [91282]
|
Facility
|
IP
|
$119.25
|
|
|
Service Code
|
HCPCS J2354
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.58 |
| Max. Negotiated Rate |
$89.44 |
| Rate for Payer: Adventist Health Commercial |
$23.85
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$76.80
|
| Rate for Payer: Cash Price |
$53.66
|
| Rate for Payer: Cigna of CA HMO/PPO |
$54.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$64.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$55.21
|
| Rate for Payer: Heritage Provider Network Senior |
$55.21
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$21.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$29.81
|
| Rate for Payer: Multiplan Commercial |
$89.44
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$43.09
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$39.48
|
|
|
OCTREOTIDE ACETATE 1,000 MCG/ML INJECTION SOLUTION [91282]
|
Facility
|
OP
|
$119.25
|
|
|
Service Code
|
HCPCS J2354
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.67 |
| Max. Negotiated Rate |
$101.36 |
| Rate for Payer: Adventist Health Commercial |
$23.85
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$73.70
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$101.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$65.59
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$89.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$10.84
|
| Rate for Payer: Blue Shield of California Commercial |
$1.67
|
| Rate for Payer: Blue Shield of California EPN |
$1.67
|
| Rate for Payer: Cash Price |
$53.66
|
| Rate for Payer: Cash Price |
$53.66
|
| Rate for Payer: Cigna of CA HMO/PPO |
$54.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$101.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$101.36
|
| Rate for Payer: Dignity Health Medicare Advantage |
$101.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$76.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$55.21
|
| Rate for Payer: Heritage Provider Network Senior |
$55.21
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$56.88
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$21.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$29.81
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$83.47
|
| Rate for Payer: Multiplan Commercial |
$89.44
|
| Rate for Payer: TriValley Medical Group Commercial |
$47.70
|
| Rate for Payer: TriValley Medical Group Senior |
$47.70
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$43.09
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$39.48
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$101.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$101.36
|
| Rate for Payer: Vantage Medical Group Senior |
$101.36
|
|
|
OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION [91279]
|
Facility
|
IP
|
$7.80
|
|
|
Service Code
|
HCPCS J2354
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.41 |
| Max. Negotiated Rate |
$5.85 |
| Rate for Payer: Adventist Health Commercial |
$1.56
|
| Rate for Payer: Adventist Health Commercial |
$2.39
|
| Rate for Payer: Adventist Health Commercial |
$0.78
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.51
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.68
|
| Rate for Payer: Cash Price |
$3.51
|
| Rate for Payer: Cash Price |
$1.76
|
| Rate for Payer: Cash Price |
$5.37
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.59
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.49
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.61
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.81
|
| Rate for Payer: Heritage Provider Network Senior |
$1.81
|
| Rate for Payer: Heritage Provider Network Senior |
$5.52
|
| Rate for Payer: Heritage Provider Network Senior |
$3.61
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.71
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.41
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.95
|
| Rate for Payer: Multiplan Commercial |
$5.85
|
| Rate for Payer: Multiplan Commercial |
$8.95
|
| Rate for Payer: Multiplan Commercial |
$2.92
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.31
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.82
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.41
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.58
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.95
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.29
|
|
|
OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION [91279]
|
Facility
|
OP
|
$11.93
|
|
|
Service Code
|
HCPCS J2354
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.67 |
| Max. Negotiated Rate |
$10.84 |
| Rate for Payer: Adventist Health Commercial |
$2.39
|
| Rate for Payer: Adventist Health Commercial |
$0.78
|
| Rate for Payer: Adventist Health Commercial |
$1.56
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.82
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.37
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.41
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.63
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.31
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.56
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.95
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.85
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.92
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$10.84
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$10.84
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$10.84
|
| Rate for Payer: Blue Shield of California Commercial |
$1.67
|
| Rate for Payer: Blue Shield of California Commercial |
$1.67
|
| Rate for Payer: Blue Shield of California Commercial |
$1.67
|
| Rate for Payer: Blue Shield of California EPN |
$1.67
|
| Rate for Payer: Blue Shield of California EPN |
$1.67
|
| Rate for Payer: Blue Shield of California EPN |
$1.67
|
| Rate for Payer: Cash Price |
$1.76
|
| Rate for Payer: Cash Price |
$5.37
|
| Rate for Payer: Cash Price |
$5.37
|
| Rate for Payer: Cash Price |
$3.51
|
| Rate for Payer: Cash Price |
$3.51
|
| Rate for Payer: Cash Price |
$1.76
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.49
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.79
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.59
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.63
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$10.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.63
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.31
|
| Rate for Payer: Dignity Health Medicare Advantage |
$6.63
|
| Rate for Payer: Dignity Health Medicare Advantage |
$10.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.81
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.61
|
| Rate for Payer: Heritage Provider Network Senior |
$1.81
|
| Rate for Payer: Heritage Provider Network Senior |
$5.52
|
| Rate for Payer: Heritage Provider Network Senior |
$3.61
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$3.72
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1.86
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$5.69
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.41
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.71
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.98
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$8.35
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$5.46
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2.73
|
| Rate for Payer: Multiplan Commercial |
$2.92
|
| Rate for Payer: Multiplan Commercial |
$5.85
|
| Rate for Payer: Multiplan Commercial |
$8.95
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.56
|
| Rate for Payer: TriValley Medical Group Commercial |
$4.77
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.12
|
| Rate for Payer: TriValley Medical Group Senior |
$3.12
|
| Rate for Payer: TriValley Medical Group Senior |
$1.56
|
| Rate for Payer: TriValley Medical Group Senior |
$4.77
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.82
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.31
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.41
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.29
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.95
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.58
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.63
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.31
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.63
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.31
|
| Rate for Payer: Vantage Medical Group Senior |
$10.14
|
| Rate for Payer: Vantage Medical Group Senior |
$6.63
|
| Rate for Payer: Vantage Medical Group Senior |
$3.31
|
|
|
OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION [91281]
|
Facility
|
IP
|
$42.00
|
|
|
Service Code
|
HCPCS J2354
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.60 |
| Max. Negotiated Rate |
$31.50 |
| Rate for Payer: Adventist Health Commercial |
$8.40
|
| Rate for Payer: Adventist Health Commercial |
$4.68
|
| Rate for Payer: Adventist Health Commercial |
$11.93
|
| Rate for Payer: Adventist Health Commercial |
$3.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$15.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.59
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$27.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$38.40
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cash Price |
$10.53
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: Cash Price |
$26.83
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$27.43
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.76
|
| Rate for Payer: Cigna of CA HMO/PPO |
$19.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$22.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.83
|
| Rate for Payer: Heritage Provider Network Commercial |
$27.61
|
| Rate for Payer: Heritage Provider Network Commercial |
$19.45
|
| Rate for Payer: Heritage Provider Network Senior |
$19.45
|
| Rate for Payer: Heritage Provider Network Senior |
$8.33
|
| Rate for Payer: Heritage Provider Network Senior |
$10.83
|
| Rate for Payer: Heritage Provider Network Senior |
$27.61
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.26
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$10.79
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$7.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.50
|
| Rate for Payer: Multiplan Commercial |
$13.50
|
| Rate for Payer: Multiplan Commercial |
$31.50
|
| Rate for Payer: Multiplan Commercial |
$17.55
|
| Rate for Payer: Multiplan Commercial |
$44.72
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.45
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$15.17
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$21.54
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.96
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$13.91
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.75
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$19.74
|
|
|
OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION [91281]
|
Facility
|
OP
|
$42.00
|
|
|
Service Code
|
HCPCS J2354
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.67 |
| Max. Negotiated Rate |
$35.70 |
| Rate for Payer: Adventist Health Commercial |
$8.40
|
| Rate for Payer: Adventist Health Commercial |
$4.68
|
| Rate for Payer: Adventist Health Commercial |
$11.93
|
| Rate for Payer: Adventist Health Commercial |
$3.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$36.85
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$25.96
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$14.46
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$50.69
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$35.70
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$19.89
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$15.30
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.90
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$12.87
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$32.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$23.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$44.72
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$17.55
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$13.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$31.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$10.84
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$10.84
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$10.84
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$10.84
|
| Rate for Payer: Blue Shield of California Commercial |
$1.67
|
| Rate for Payer: Blue Shield of California Commercial |
$1.67
|
| Rate for Payer: Blue Shield of California Commercial |
$1.67
|
| Rate for Payer: Blue Shield of California Commercial |
$1.67
|
| Rate for Payer: Blue Shield of California EPN |
$1.67
|
| Rate for Payer: Blue Shield of California EPN |
$1.67
|
| Rate for Payer: Blue Shield of California EPN |
$1.67
|
| Rate for Payer: Blue Shield of California EPN |
$1.67
|
| Rate for Payer: Cash Price |
$26.83
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: Cash Price |
$26.83
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cash Price |
$10.53
|
| Rate for Payer: Cash Price |
$10.53
|
| Rate for Payer: Cigna of CA HMO/PPO |
$27.43
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.76
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$19.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$35.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$15.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$19.89
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$50.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$15.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$50.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$35.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$19.89
|
| Rate for Payer: Dignity Health Medicare Advantage |
$35.70
|
| Rate for Payer: Dignity Health Medicare Advantage |
$19.89
|
| Rate for Payer: Dignity Health Medicare Advantage |
$50.69
|
| Rate for Payer: Dignity Health Medicare Advantage |
$15.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$38.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$26.88
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.83
|
| Rate for Payer: Heritage Provider Network Commercial |
$19.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$27.61
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.33
|
| Rate for Payer: Heritage Provider Network Senior |
$19.45
|
| Rate for Payer: Heritage Provider Network Senior |
$10.83
|
| Rate for Payer: Heritage Provider Network Senior |
$27.61
|
| Rate for Payer: Heritage Provider Network Senior |
$8.33
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$20.03
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$28.44
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$8.59
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$11.16
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$7.60
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$10.79
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.85
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$29.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$16.38
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$12.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$41.74
|
| Rate for Payer: Multiplan Commercial |
$44.72
|
| Rate for Payer: Multiplan Commercial |
$31.50
|
| Rate for Payer: Multiplan Commercial |
$17.55
|
| Rate for Payer: Multiplan Commercial |
$13.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$7.20
|
| Rate for Payer: TriValley Medical Group Commercial |
$16.80
|
| Rate for Payer: TriValley Medical Group Commercial |
$23.85
|
| Rate for Payer: TriValley Medical Group Commercial |
$9.36
|
| Rate for Payer: TriValley Medical Group Senior |
$9.36
|
| Rate for Payer: TriValley Medical Group Senior |
$23.85
|
| Rate for Payer: TriValley Medical Group Senior |
$16.80
|
| Rate for Payer: TriValley Medical Group Senior |
$7.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$21.54
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.45
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$15.17
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.75
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$13.91
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.96
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$19.74
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$15.30
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$50.69
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$19.89
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$35.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$35.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$19.89
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$50.69
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$15.30
|
| Rate for Payer: Vantage Medical Group Senior |
$35.70
|
| Rate for Payer: Vantage Medical Group Senior |
$19.89
|
| Rate for Payer: Vantage Medical Group Senior |
$50.69
|
| Rate for Payer: Vantage Medical Group Senior |
$15.30
|
|
|
OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION [91278]
|
Facility
|
OP
|
$3.48
|
|
|
Service Code
|
HCPCS J2354
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$10.84 |
| Rate for Payer: Adventist Health Commercial |
$0.70
|
| Rate for Payer: Adventist Health Commercial |
$1.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.34
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.15
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.96
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.59
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.97
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.91
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.61
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$10.84
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$10.84
|
| Rate for Payer: Blue Shield of California Commercial |
$1.67
|
| Rate for Payer: Blue Shield of California Commercial |
$1.67
|
| Rate for Payer: Blue Shield of California EPN |
$1.67
|
| Rate for Payer: Blue Shield of California EPN |
$1.67
|
| Rate for Payer: Cash Price |
$1.57
|
| Rate for Payer: Cash Price |
$2.43
|
| Rate for Payer: Cash Price |
$1.57
|
| Rate for Payer: Cash Price |
$2.43
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.96
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.59
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.59
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.96
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.96
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.61
|
| Rate for Payer: Heritage Provider Network Senior |
$2.50
|
| Rate for Payer: Heritage Provider Network Senior |
$1.61
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1.66
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$2.58
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.98
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.87
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$3.78
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2.44
|
| Rate for Payer: Multiplan Commercial |
$4.05
|
| Rate for Payer: Multiplan Commercial |
$2.61
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.39
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.16
|
| Rate for Payer: TriValley Medical Group Senior |
$1.39
|
| Rate for Payer: TriValley Medical Group Senior |
$2.16
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.26
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.95
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.79
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.59
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.59
|
| Rate for Payer: Vantage Medical Group Senior |
$4.59
|
| Rate for Payer: Vantage Medical Group Senior |
$2.96
|
|
|
OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION [91278]
|
Facility
|
IP
|
$3.48
|
|
|
Service Code
|
HCPCS J2354
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$2.61 |
| Rate for Payer: Adventist Health Commercial |
$0.70
|
| Rate for Payer: Adventist Health Commercial |
$1.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.48
|
| Rate for Payer: Cash Price |
$1.57
|
| Rate for Payer: Cash Price |
$2.43
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.88
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.61
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.50
|
| Rate for Payer: Heritage Provider Network Senior |
$2.50
|
| Rate for Payer: Heritage Provider Network Senior |
$1.61
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.63
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.35
|
| Rate for Payer: Multiplan Commercial |
$2.61
|
| Rate for Payer: Multiplan Commercial |
$4.05
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.95
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.26
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.79
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.15
|
|
|
OCTREOTIDE,MICROSPHERES 20 MG INTRAMUSCULAR WRAP, LONG-ACTING RELEASE [40824435]
|
Facility
|
OP
|
$5,539.56
|
|
|
Service Code
|
HCPCS J2353
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$197.19 |
| Max. Negotiated Rate |
$4,154.67 |
| Rate for Payer: Adventist Health Commercial |
$1,107.91
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,423.45
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$260.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$228.91
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$228.91
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$197.19
|
| Rate for Payer: Blue Shield of California Commercial |
$203.24
|
| Rate for Payer: Blue Shield of California EPN |
$203.24
|
| Rate for Payer: Cash Price |
$2,492.80
|
| Rate for Payer: Cash Price |
$2,492.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,548.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$260.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$228.91
|
| Rate for Payer: Dignity Health Medicare Advantage |
$228.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,545.32
|
| Rate for Payer: EPIC Health Plan Medicare |
$208.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,564.82
|
| Rate for Payer: Heritage Provider Network Senior |
$2,564.82
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$208.10
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$2,642.37
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1,002.66
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$239.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,384.89
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$278.85
|
| Rate for Payer: Multiplan Commercial |
$4,154.67
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,215.82
|
| Rate for Payer: TriValley Medical Group Senior |
$2,215.82
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,001.44
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,834.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$260.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$228.91
|
| Rate for Payer: Vantage Medical Group Senior |
$228.91
|
|
|
OCTREOTIDE,MICROSPHERES 20 MG INTRAMUSCULAR WRAP, LONG-ACTING RELEASE [40824435]
|
Facility
|
IP
|
$5,539.56
|
|
|
Service Code
|
HCPCS J2353
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,002.66 |
| Max. Negotiated Rate |
$4,154.67 |
| Rate for Payer: Adventist Health Commercial |
$1,107.91
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,567.48
|
| Rate for Payer: Cash Price |
$2,492.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,548.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,991.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,564.82
|
| Rate for Payer: Heritage Provider Network Senior |
$2,564.82
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1,002.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,384.89
|
| Rate for Payer: Multiplan Commercial |
$4,154.67
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,001.44
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,834.15
|
|
|
OCTREOTIDE,MICROSPHERES 30 MG INTRAMUSCULR WRAP, LONG-ACTING RELEASE [40824436]
|
Facility
|
IP
|
$8,295.07
|
|
|
Service Code
|
HCPCS J2353
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,501.41 |
| Max. Negotiated Rate |
$6,221.30 |
| Rate for Payer: Adventist Health Commercial |
$1,659.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5,342.03
|
| Rate for Payer: Cash Price |
$3,732.78
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3,815.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$4,479.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,840.62
|
| Rate for Payer: Heritage Provider Network Senior |
$3,840.62
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1,501.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,073.77
|
| Rate for Payer: Multiplan Commercial |
$6,221.30
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,997.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,746.50
|
|
|
OCTREOTIDE,MICROSPHERES 30 MG INTRAMUSCULR WRAP, LONG-ACTING RELEASE [40824436]
|
Facility
|
OP
|
$8,295.07
|
|
|
Service Code
|
HCPCS J2353
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$197.19 |
| Max. Negotiated Rate |
$6,221.30 |
| Rate for Payer: Adventist Health Commercial |
$1,659.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5,126.35
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$260.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$228.91
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$228.91
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$197.19
|
| Rate for Payer: Blue Shield of California Commercial |
$203.24
|
| Rate for Payer: Blue Shield of California EPN |
$203.24
|
| Rate for Payer: Cash Price |
$3,732.78
|
| Rate for Payer: Cash Price |
$3,732.78
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3,815.73
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$260.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$228.91
|
| Rate for Payer: Dignity Health Medicare Advantage |
$228.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$5,308.84
|
| Rate for Payer: EPIC Health Plan Medicare |
$208.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,840.62
|
| Rate for Payer: Heritage Provider Network Senior |
$3,840.62
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$208.10
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$3,956.75
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1,501.41
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$239.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,073.77
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$278.85
|
| Rate for Payer: Multiplan Commercial |
$6,221.30
|
| Rate for Payer: TriValley Medical Group Commercial |
$3,318.03
|
| Rate for Payer: TriValley Medical Group Senior |
$3,318.03
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,997.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,746.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$260.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$228.91
|
| Rate for Payer: Vantage Medical Group Senior |
$228.91
|
|
|
OCTREOTIDE,MICROSPHERES ER 10 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE [204871]
|
Facility
|
OP
|
$4,228.12
|
|
|
Service Code
|
HCPCS J2353
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$197.19 |
| Max. Negotiated Rate |
$3,171.09 |
| Rate for Payer: Adventist Health Commercial |
$845.62
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,612.98
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$260.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$228.91
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$228.91
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$197.19
|
| Rate for Payer: Blue Shield of California Commercial |
$203.24
|
| Rate for Payer: Blue Shield of California EPN |
$203.24
|
| Rate for Payer: Cash Price |
$1,902.65
|
| Rate for Payer: Cash Price |
$1,902.65
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,944.94
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$260.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$228.91
|
| Rate for Payer: Dignity Health Medicare Advantage |
$228.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,706.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$208.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,957.62
|
| Rate for Payer: Heritage Provider Network Senior |
$1,957.62
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$208.10
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$2,016.81
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$765.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$239.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,057.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$278.85
|
| Rate for Payer: Multiplan Commercial |
$3,171.09
|
| Rate for Payer: TriValley Medical Group Commercial |
$1,691.25
|
| Rate for Payer: TriValley Medical Group Senior |
$1,691.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,527.62
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,399.93
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$260.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$228.91
|
| Rate for Payer: Vantage Medical Group Senior |
$228.91
|
|
|
OCTREOTIDE,MICROSPHERES ER 10 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE [204871]
|
Facility
|
IP
|
$4,228.12
|
|
|
Service Code
|
HCPCS J2353
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$765.29 |
| Max. Negotiated Rate |
$3,171.09 |
| Rate for Payer: Adventist Health Commercial |
$845.62
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,722.91
|
| Rate for Payer: Cash Price |
$1,902.65
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,944.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,283.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,957.62
|
| Rate for Payer: Heritage Provider Network Senior |
$1,957.62
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$765.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,057.03
|
| Rate for Payer: Multiplan Commercial |
$3,171.09
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,527.62
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,399.93
|
|
|
OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE [204610]
|
Facility
|
OP
|
$5,539.56
|
|
|
Service Code
|
HCPCS J2353
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$197.19 |
| Max. Negotiated Rate |
$4,154.67 |
| Rate for Payer: Cigna of CA HMO/PPO |
$2,548.20
|
| Rate for Payer: Adventist Health Commercial |
$1,107.91
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,423.45
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$260.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$228.91
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$228.91
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$197.19
|
| Rate for Payer: Blue Shield of California Commercial |
$203.24
|
| Rate for Payer: Blue Shield of California EPN |
$203.24
|
| Rate for Payer: Cash Price |
$2,492.80
|
| Rate for Payer: Cash Price |
$2,492.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$260.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$228.91
|
| Rate for Payer: Dignity Health Medicare Advantage |
$228.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,545.32
|
| Rate for Payer: EPIC Health Plan Medicare |
$208.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,564.82
|
| Rate for Payer: Heritage Provider Network Senior |
$2,564.82
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$208.10
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$2,642.37
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1,002.66
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$239.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,384.89
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$278.85
|
| Rate for Payer: Multiplan Commercial |
$4,154.67
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,215.82
|
| Rate for Payer: TriValley Medical Group Senior |
$2,215.82
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,001.44
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,834.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$260.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$228.91
|
| Rate for Payer: Vantage Medical Group Senior |
$228.91
|
|
|
OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE [204610]
|
Facility
|
IP
|
$5,539.56
|
|
|
Service Code
|
HCPCS J2353
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,002.66 |
| Max. Negotiated Rate |
$4,154.67 |
| Rate for Payer: Adventist Health Commercial |
$1,107.91
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,567.48
|
| Rate for Payer: Cash Price |
$2,492.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,548.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,991.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,564.82
|
| Rate for Payer: Heritage Provider Network Senior |
$2,564.82
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1,002.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,384.89
|
| Rate for Payer: Multiplan Commercial |
$4,154.67
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,001.44
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,834.15
|
|
|
OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE [204612]
|
Facility
|
IP
|
$8,295.07
|
|
|
Service Code
|
HCPCS J2353
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,501.41 |
| Max. Negotiated Rate |
$6,221.30 |
| Rate for Payer: Adventist Health Commercial |
$1,659.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5,342.03
|
| Rate for Payer: Cash Price |
$3,732.78
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3,815.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$4,479.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,840.62
|
| Rate for Payer: Heritage Provider Network Senior |
$3,840.62
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1,501.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,073.77
|
| Rate for Payer: Multiplan Commercial |
$6,221.30
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,997.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,746.50
|
|
|
OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE [204612]
|
Facility
|
OP
|
$8,295.07
|
|
|
Service Code
|
HCPCS J2353
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$197.19 |
| Max. Negotiated Rate |
$6,221.30 |
| Rate for Payer: Adventist Health Commercial |
$1,659.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5,126.35
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$260.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$228.91
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$228.91
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$197.19
|
| Rate for Payer: Blue Shield of California Commercial |
$203.24
|
| Rate for Payer: Blue Shield of California EPN |
$203.24
|
| Rate for Payer: Cash Price |
$3,732.78
|
| Rate for Payer: Cash Price |
$3,732.78
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3,815.73
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$260.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$228.91
|
| Rate for Payer: Dignity Health Medicare Advantage |
$228.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$5,308.84
|
| Rate for Payer: EPIC Health Plan Medicare |
$208.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,840.62
|
| Rate for Payer: Heritage Provider Network Senior |
$3,840.62
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$208.10
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$3,956.75
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1,501.41
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$239.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,073.77
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$278.85
|
| Rate for Payer: Multiplan Commercial |
$6,221.30
|
| Rate for Payer: TriValley Medical Group Commercial |
$3,318.03
|
| Rate for Payer: TriValley Medical Group Senior |
$3,318.03
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,997.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,746.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$260.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$228.91
|
| Rate for Payer: Vantage Medical Group Senior |
$228.91
|
|
|
OFLOXACIN 0.3 % EAR DROPS [22257]
|
Facility
|
IP
|
$3.60
|
|
|
Service Code
|
NDC 7075660915
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$2.70 |
| Rate for Payer: Adventist Health Commercial |
$0.72
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.32
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.94
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.44
|
| Rate for Payer: Heritage Provider Network Senior |
$2.44
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.90
|
| Rate for Payer: Multiplan Commercial |
$2.70
|
|
|
OFLOXACIN 0.3 % EAR DROPS [22257]
|
Facility
|
OP
|
$3.60
|
|
|
Service Code
|
NDC 7075660915
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$3.06 |
| Rate for Payer: Adventist Health Commercial |
$0.72
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.98
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.70
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.80
|
| Rate for Payer: Blue Shield of California Commercial |
$2.20
|
| Rate for Payer: Blue Shield of California EPN |
$1.76
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.06
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.23
|
| Rate for Payer: Heritage Provider Network Senior |
$2.23
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1.72
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.90
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2.52
|
| Rate for Payer: Multiplan Commercial |
$2.70
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.44
|
| Rate for Payer: TriValley Medical Group Senior |
$1.44
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.80
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.06
|
| Rate for Payer: Vantage Medical Group Senior |
$3.06
|
|
